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  • Health History

    Transféré par

    Avi Baron
    14 vues3 pages
    This document contains medical information for a student named FirstName Lastname, including their age, birthdate, grade, gender, contact information for two custodial parents and an emergency contact, insurance information, allergies, medications, dietary restrictions, responses to general health questions, immunization history, and indication that over-the-counter medications are allowed. It lists three medication allergies, three food allergies, and three other allergies along with reactions. It also notes that the student takes two prescribed medications twice daily and wears glasses.

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    This document contains medical information for a student named FirstName Lastname, including their age, birthdate, grade, gender, contact information for two custodial parents and an emergency contact, insurance information, allergies, medications, dietary restrictions, responses to general health questions, immunization history, and indication that over-the-counter medications are allowed. It lists three medication allergies, three food allergies, and three other allergies along with reactions. It also notes that the student takes two prescribed medications twice daily and wears glasses.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    14 vues3 pages

    Health History

    Transféré par

    Avi Baron
    This document contains medical information for a student named FirstName Lastname, including their age, birthdate, grade, gender, contact information for two custodial parents and an emergency contact, insurance information, allergies, medications, dietary restrictions, responses to general health questions, immunization history, and indication that over-the-counter medications are allowed. It lists three medication allergies, three food allergies, and three other allergies along with reactions. It also notes that the student takes two prescribed medications twice daily and wears glasses.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 3

    Name: Lastname FirstName Session

    Age: Age Birth date: Birthdate Grade: Grade Gender: Female

    Custodial Parent #1 – ParentName1 Parent1Phone

    Parent1Address

    Custodial Parent #2/Emergency Contact – ParentName2 Parent2Phone

    Parent2Address

    Emergency Contact: EmergencyContact EmergencyContactRelation EmergencyContactPhone

    INSURANCE – Insurance?

    Carrier or Plan: InsuranceCarrier Group # InsuranceGroup

    ALLERGIES

    Medication Allergy #1 : Reaction:

    Medication Allergy #2 Reaction:

    Medication Allergy #3 Reaction

    Food Allergy #1: Reaction:

    Food Allergy #2: Reaction #2:

    Food Allergy #3: Reaction:

    Other Allergy: Reaction:

    Other Allergy: Reaction:

    Other Allergy: Reaction:

    MEDICATIONS

    This Person takes no medication: NoMeds

    This Person takes medications: Meds

    Med #1: Dosage: Time of Day: Reason:

    Med #2: Dosage: Time of Day: Reason:

    Med #3: Dosage: Time of Day: Reason:

    Med #4: Dosage: Time of Day: Reason:


    RESTRICTIONS

    Dietary:

    Does not eat nuts:

    Other: 0 Describe:

    Explain Restrictions:

    GENERAL QUESTIONS

    Recent injury, illness or infections disease: No Back Problems: No

    Chronic or recurring illness/condition: No Problems with Joints (knees, ankles) No

    Had Surgery: No Orthodontic Appliance being brought to camp : No

    Frequent Headaches: No Skin Problems (itching, rash, acne) No

    Head Injury: No Diabetes: No

    Knocked Unconscious: No Asthma: No

    Weare Glasses, Contacts or Protective Eyewear: Yes Mono in the past 12 months: No

    Frequent Ear Infections: No Diarrhea/constipation: No

    Passed out during or after exercise: No Sleep Walking: No

    Dizzy during or after Exercise: No Abnormal Menstrual History: No

    Seizure: No Bedwetting History: No

    Chest Pain during or after exercise: No Eating Disorder: No

    High Blood Pressure: No Emotional Difficulties for which professional help was
    sought? No
    Diagnosed with a heart murmur: No
    Explain:
    This participant has had the following:

    Shots: TB Mantoux Test:

    Result of TB Test:

    DTP: 1/00 3/00 5/00 2/01 12/04

    TD(Tetanus/Diphteria):

    Tetanus:

    Polio: 1/00 3/00 11/00 12/04

    MMR: 11/00 12/04

    Measles:

    Mumps:

    Rubella:

    Haemphilius influenza B: 1/00 3/00 5/00 2/01

    Hepatitis B: 5/00 8/00 2/01

    Varicella: 11/00

    Additional Information:

    OTC Meds ok?: Yes

    If not, Please List:

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